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Prostate Cancer > Background and recommendations > Flashcards

Background and recommendations Flashcards

1
Q

RTOG Rectal constraints?

A

V70 < 20%

V50 < 50%

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2
Q

RTOG Bladder constraints?

A

V70 < 30%

V55 < 50%

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3
Q

Femoral head constraints?

A

V55 < 2 cc

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4
Q

Penile bulb

A

Mean dose < 50 Gy

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5
Q

What is the dose to PTV1 for LR patients?

A

78 Gy at 2 Gy/fx

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6
Q

Contraindications to RT for prostate cancer?

A
  1. Inflammatory bowel disease

2. Scleroderma or Lupus

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7
Q

What imaging do you need at diagnosis?

A
  1. Bone scan if intermediate risk or higher

2. CT scan of the abdomen/pelvis if intermediate risk or higher

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8
Q

What are the critical elements of the PE?

A
  1. DRE with estimation of prostate size and tumor size and laterality in the prostate
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9
Q

What is PSA density?

A
  1. PSA value/Prostate size
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10
Q

What qualifies as low risk per NCCN?

A

T1-2a, GS 6 or less, PSA < 10

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11
Q

What qualifies as very low risk per NCCN?

A

T1c, GS 6, PSA < 10, < 3 cores+, 50% or less of any core involved with cancer, PSA density < 0.15

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12
Q

What qualifies as very high risk prostate cancer per NCCN?

A

T3b-T4

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13
Q

What qualifies as high risk prostate cancer per NCCN?

A

T3a, GS 8 or higher, PSA 20 or higher

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14
Q

What qualifies as intermediate risk?

A

T2b-T2c, GS 7, PSA 10-20

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15
Q

T3a

A

extracapsular extension

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16
Q

T3b

A

seminal vesicle invasion

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17
Q

T4

A

fixed, invades adjacent structures

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18
Q

T2a

A

Tumor involving 50% or less of one lobe

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19
Q

T2b

A

Tumor involving more than 50% of one lobe

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20
Q

T2c

A

tumor involving both lobes

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21
Q

T1c

A

Disease discovered because of elevated PSA, not evidence of prostate nodules on exam

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22
Q

Roach Formula for LN risk

A

A method of estimating postive pelvic node risk based on PSA and GS

2/3 x PSA +(10 x (GS-6))

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23
Q

What is the RTOG/Phoenix definitive of biochemical failure? Which patients is it applicable for?

A
  1. Nadir + 2 ng/ml = failure or any patient confirmed clinically to have recurrent prostate cancer with biopsy or treated for recurrence
  2. Patient s/p EBRT +/- short term ADT
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24
Q

ASTRO definition of biochemical failure?

A

3 consecutive rises in PSA; date of failure is backdated midway b/w first rise and nadir or between nadir and any rise that provokes initiation of salvage therapy; requires 2 years or more of f/u.

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25
Q

What is the only contraindication to RT?

A
  1. Prior RT to the pelvis
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26
Q

When is treatment recommended for very low risk patients by the NCCN? Is active surveillance also an option?

A

When the estimated survival is > 20 years

Active surveillance is an option

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27
Q

When is active surveillance recommended by the NCCN for patients with low risk disease?

A

When the estimated survival is < 10 years

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28
Q

What is active surveillance per the NCCN?

A
  1. PSA every 6 months
  2. DRE every 12 months

For patients with more than a 10 year life expectancy, a TRUS and biopsy is recommended every 12 months

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29
Q

What are the options for patients with intermediate risk disease and a < 10 year life expectancy?

A
  1. Active surveillance (no biopsy)

2. RT +/- short term ADT +/- brachytherapy boost

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30
Q

What are the options for patients with intemediate risk disease and a > 10 year life expectancy?

A
  1. Surgery +/- RT for adverse features
    1. Active surveillance (no biopsy)
  3. RT +/- short term ADT +/- brachytherapy boost
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31
Q

What are the options for patients with high risk cancer?

A
  1. RT + long term ADT (2-3) years
  2. EBRT + brachy boost+/ long term ADT (2-3 years)
  3. Surgery for patients without fixation +/- RT for high risk features. If LN mets then observation or ADT.
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32
Q

What are the options for patients with metastatic disease at presentation?

A
  1. ADT

2. RT + long term ADT

33
Q

How should you follow patients with initially localized disease?

A
  1. PSA every 6 mo for 5 years and then yearly
  2. DRE very year unless PSA is undetectable*

Except when you have a PSA negative cancer

34
Q

What defines biochemical failure after surgery?

A
  1. Failure of PSA to become undetectable
  2. Undetectable PSA after RP but with subsequent PSA increases on 2 or more determinations to atleast a threshold level of 0.2
35
Q

What imaging is needed when a patient fails biochemically after RP?

A
  1. Bone scan
  2. CT of chest/abdomen/pelvis
  3. TRUS and biopsy if a mass is seen in the prostate bed
36
Q

What recommendation for patients who have biochemically failed after RP and no evidence of distant mets can be found?

A
  1. RT +/- ADT

2. Observation

37
Q

What recommendation for patients who have biochemically failed after RP or RT and positive for distant mets can be found?

A
  1. ADT +/- RT to metastases involving weight bearing bones or symptomatic
  2. Observation
38
Q

What recommendation for patients who have biochemically failed after RT and distant mets can not be found?

A

If patient was a T1-2, NX or N0 initially and life expectancy is > 10 years and PSA < 10 determine if the patient has signs of distant mets

  1. CT scan of abdomen/pelvis
  2. Bone scan

If negative for distant mets, then biopsy prostate and consider observation, RP, cryosurgery, or brachytherapy.

39
Q

What CTV volumes are used for intermediate risk patients? Dose?

A
  1. CTV 46 = prostate and proximal SV 2 cm

2. CTV 78 = Boost to prostate alone

40
Q

What CTV volumes are used for high risk patients with < 15% risk of LN?

A
  1. CTV 78 = Prostate and prox 2 cm of SV
41
Q

What CTV volumes are used for high risk patients with > 15% risk of LN?

A
  1. CTV 50.4 Pelvic nodes + Prostate and proximal SV

2. CTV 78= Prostate and proximal SV

42
Q

CT simulation steps

A
  1. Supine
  2. Arms on Chest
  3. Uretrhogram if an MR is not available
  4. Indexed bag
  5. Rectal balloon, 80 cc filled with saline
43
Q

What nodes should be included when delivering ENI?

A
  1. Obturator
  2. Internal/external iliac
  3. Common iliacs from level L5-S1 down
  4. Presacral (S1-3)
44
Q

What are the indications for adjuvant RT?

A
  1. Positive margin

2. T3-4 disease

45
Q

What is the highest LN risk for a patient with intermediate risk PC on the MSK nomogram?

A

8.6%

46
Q

What is the highest risk for LNs for a patient with intermediate risk disease on the MSK nomogram with a PSA <10?

A

5%

47
Q

What is the highest risk LN for a really high risk prostate (T3-4, PSA > 50, GS10) cancer on the MSK scale?

A

80%

48
Q

UFPTI PR06 Focus

A

Adjuvant or Salvage RT for prostate cancer

49
Q

UFPTI PR05 Focus

A

High risk prostate cancer

50
Q

RTOG 0534 Arms

A

Salvage RT after RP

  1. Prostate bed RT
  2. Prostate bed RT + ADT (short term)
  3. Prostate bed + ENI + ADT (short term)
51
Q

PR05 eligibility criteria

A
  1. PSA < 20 but less than 40 or GS 8-10 or T3-4
  2. N0 and M0
  3. No prior MI or CHF
  4. No previous local prostate cancer treatment
  5. No previous pelvic RT
  6. No previous chemotherapy
  7. PSA must be drawn before biopsy or atleast 3 weeks after
  8. Biopsy within 6 months, atleast 10 core
52
Q

What percentage of patients will have a PSA bounce? What is the median rise? What is the median time to bounce?

A
  1. 26%
  2. 0.7
  3. 21 months
53
Q

What is the post treatment median nadir after low dose EBRT?

A

0.7

54
Q

When you use either ASTRO or Phoenix definition early in follow up which produces worse biochemical failure outcomes?

A

The ASTRO definition makes biochemical failures more likely earlier in follow up.

55
Q

What is the positive predictive value of clinical failure of the Phoenix definition? ASTRO definition?

A
  1. 36%

2. 31%

56
Q

What is the negative predictive value for clinical failure for the Phoenix definition? ASTRO definition?

A
  1. 88%

2. 92%

57
Q

What were the major drawbacks of using the ASTRO definition of biochemical failure?

A
  1. Its results depended on the frequency and duration of follow up
  2. It was developed only for EBRT monotherapy
  3. There is a backdating censoring artifact
  4. PSA lead to false declarations of failure in many men with PSA bounce which can happen in 26% of casesesp. in patients with ADT or brachy
  5. It does not meet proportional hazard assumptions
  6. It is not correlate well with clinical progression
58
Q

After ADT when do men recover pretreatment testosterone levels?

A

A median of 10 months for 95% of men

59
Q

What PSA kinetic after treatment is associated with prostate cancer mortality?

A

PSADT of < 12 months

60
Q

When are you now allowed to report biochemical failure using the ASTRO definition?

A

After brachytherapy or EBRT alone.

One must report biochemical failure at a date 2 years earlier than median follow up.

61
Q

What is the major problem with defining biochemical failure via the Phoenix definition alone in papers?

A

Patients in RT studies with short follow up appear do better than older series or surgical series initially when the Phoenix definition is used.

62
Q

In which patients with a rising PSA must one be very cautious about before a Phoenix Definition of biochemical failure is apparent?

A

Young patients with slowly rising PSAs who might be candidates for local salvage

63
Q

According to the NCCN, when do you order a bone scan?

A
  1. High risk
  2. T2 and PSA > 10
  3. Symptomatic patient
64
Q

According to the NCCN, when do you order a CT scan and/or MR of the pelvis?

A
  1. T3-4

2. T1-2 and greater than a 10% risk of nodal disease on a nomogram

65
Q

What percentage of prostate cancer arises in the peripheral zone?

A

66%

66
Q

What percentage of patients have a high gleason score at RP then at biopsy?

A

33%

67
Q

Which factors can increase PSA?

A
  1. PC
  2. BPH
  3. Recent ejaculation
  4. Prostate manipulation
  5. Infection (prostatitis)
68
Q

What is the mean time to PSA nadir?

A

18 months

69
Q

How has PSA screening affected the risk for metastatic disease being discovered at diagnosis?

A

PSA screening has lowered the risk of mets at diagnosis by 54%

70
Q

What is the median time to metastasis after biochemical recurrence? To death?

A

The median time to metastasis is 8 years.

The median time to death is 13 years.

71
Q

What are the common predictors of a poorer prognosis after biochemical failure following local therapy?

A
  1. PSA DT of 3 months or less
  2. Nodal disease at presentation
  3. Gleason 8 -10 at presentation
  4. T3b disease at presentation
72
Q

How do prostate bony metastasis usually look?

A

Osteoblastic

73
Q

RTOG Femoral head constraint?

A

V50 < 5%

74
Q

Quantec penile bulb dose constraint?

A

Mean dose to 95% of volume < 50 Gy

75
Q

What 4 variations of PSA can determine a patients risk for prostate cancer?

A
  1. PSA as a function of age
  2. PSA velocity
  3. PSA density
  4. Ratio of free to total PSA
76
Q

What cutoff of free PSA seems to be prognostic?

A

Highly suspicious for prostate cancer: < 7%

Rarely associated with prostate cancer: > 20%

77
Q

What are the cutoffs for normal PSA for patients 40-59?

A

Age 40-49: 1.5 to 2.5

Age 50-59: 2.5 to 4

78
Q

What are the cutoffs for normal PSA for patients 40-59?

A

Age 60-69: 4-5.5

Age 70-79: 5.5 to 7

Prostate Cancer (2 decks)

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